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Thursday, July 29, 2010

Difficult patients - difficult doctors

Forget about the law for a moment, and suspend your disbelief: Are patients entitled to reject a particular attending physician because of the doctor's color of her skin, her religious beliefs or for no reason at all? This is the subject of a debate currently ongoing on an international listserv of bioethicists. I must say, I have never given much thought to this issue. I mean, it is straightforward that doctors could not reject to attend to patients for any of those reasons - there are as few conscientious objection rationales for particular procedures, but really even they don't make much sense to my mind and should be rejected. The point is that doctors are professionals and need to act as professionals. Non-professional reasons (aka skin-color, party membership and other such matters) don't count as acceptable rationales for refusing to attend to particular patients.

However, what about patients. There's all sorts of people out there, and some are morons. So, what if a patient doesn't want to be seen by a particular doctor for moronic reasons, say the doctor's membership in a particular church, the doctor's skin color and other non-professional matters. Some of my colleagues, certainly colleagues I hold in high esteem, argue that motives that are unacceptable (eg racist motives) should be ignored and the patient request declined. My gut feeling was initially that that probably is the right approach. Why give in to blatantly racist attitudes for instance. Stuff em I thought.

Well, here's the counter argument: some other bioethicists claim (they did not provide evidence, but let's assume their claim is correct) there is evidence that having to deal with attending doctors that patients can't cope with (for whatever reasons) has a negative impact on health outcomes, and those health outcomes should be our primary concern. That argument persuaded me - that is until I discover that there's no evidence to support the empirical claim I have just outlined.

8 comments:

I can see it now: "I'm going to treat this patient, no matter what she wants!" Yeah, that sounds great. And as for the "stuff em" attitude towards patient requests, wow! Patients aren't hogs to be moved through the system with electric prods, they're the reason hospitals exist and they're the people that the doctors are trying to please. How can you square that with the "stuff patients" attitude?

Doctors are the professionals here and patients are often scared, always needy people who come in off the street, looking for help. Even if you believed that switching doctors wouldn't help the patient but would actually harm them, if they're adults that's their decision to make.

And if politeness, equality, service or compassion don't appeal to you, why not self-interest. Imagine that a patient demands to see another doctor and you refuse and treat them (forcibly?) anyway but something goes wrong. I expect that having the patient disagreeing with you from the beginning would make any legal defence much more difficult.

Even morons deserve good health care. But I agree that it's a question with many facets.

Imagine a patient who isn't a racist, but she has a mental illness causing her to believe that people of a certain race are actually evil Martians. (There may be an inherent contradiction in this, but let's imagine her anyway.) Her insanity shouldn't disqualify her from any health care, should it? And if not, why should her racist twin brother be disqualified for the same behaviors?

And still, if she walks out of the clinic because of her prejudices, do we treat her as insane (and go after her) or as racist (and sneer after her)?

It happened to me that a doctor refused to treat me on non-medical ground. Explained reasons gently, issue I came with wasn't requiring immediate attention, got recommendations of actually much better specialists... I don't think there was anything unethical about it.

My gut is that they're probably entitled to reject a particular attending physician provided they are willing to live with the consequences of their decision. So if the patient dies, condition worsens, etc...I would imagine that's the outcome of exercising your choice.

I do not want to be treated by an abortion-forbidder; and now, with living-wills legal and enforcable in Germany, I am deprived of a means to find out whether a new doctor will force me to die the slow painful christian way I wanted to exclude!AND: I have been discriminated against because of looks my whole life, because I am fat.

It is an interesting discussion. Even if there is evidence of an adverse health outcome associated with being treated by a physician a patient dislikes, the patient should be able to reject treatment, but not of requesting another physician. This assuming a health care system where individuals share opportunity of service (as in a national health care system), where their "moronic" reasons have used up limited resources someone else might have benefited from. Scarce resources (physician time for example) should be distributed rationally...."moronic" reasons do not justify allocation of extra resources for this population

It's not clear to me that the fact that a doctor belongs to a particular religion is always 'moronic' reason for not wanting to be treated by them.

I'm not sure, for example, that I'd want to get advice on contraception or abortion from an evangelical Christian. Norf would I be comfortable with an anaesthetist (or an Obstetrician) who was a Christian Scientist.